Paralysis in Children

This stimulating and provocative book has been written by a working party set up by the Royal College of General Practitioners and consisting of six outstanding general practitioners, all of whom have had extensive experience of teaching. The object of the book is to give guidance to teachers involved in the training of young doctors for a career in general practice. The larger part of the book is devoted to the content of vocational training and describes in detail what the authors consider to be the essential ground to be covered in postgraduate training in the setting of general practice. This section deals with health and disease, human development, human behaviour, medicine and society, and the organization of general practice, and provides a valuable practical guide which may provoke mild criticism but is unlikely to lead to heated discussion. The same cannot be said for the chapters dealing with consultation in general practice. There will be many raised eyebrows as readers, if they are traditionalists and unfamiliar with the terms used, meet for the first time the language and approach of the behavioural scientists and the swing from the disease-centred approach on which most undergraduate teaching is based to the patient-centred approach advocated by the authors. However, it would be a very unimaginative doctor, particularly if he has had experience in general practice, who is not stimulated by this approach to patient care, because all general practitioners are, or should be, familiar with the feeling of inadequacy induced by meeting a clinical situation which is not soluble in traditional medical terms. Expressed another way, the undergraduate is taught to make a diagnosis by collecting evidence which will lead him to deduce what morbid processes are at work and thence to determine what effect medical intervention will have on these processes. The authors put forward the view that this approach lacks the breadth and depth required in the management of patients in general practice and that unless we as doctors have a better understanding of the influence of the psychosocial component in illness we will be unable to meet the needs of our patients. No doubt the authors would regard this as an oversimplified version of a most complex subject, but there is clearly a need to try to clear the air. Here we have a group of influential general practitioners who, at the instigation of an increasingly influential Royal College of General Practitioners, have written a book containing views which are perhaps not revolutionary, but are certainly unusual and will lead, I suggest, to the following questions being asked. Is this method of approaching patient care necessary, practicable, effective, and acceptable to the majority of patients in the setting of general practice as we know it today? If so how, and perhaps more important when, are we going to train doctors along the lines suggested? Is it really possible to influence doctors undergoing vocational training after five years of traditional undergraduate education and several years of traditional postgraduate training? Is there a danger that the pendulum may swing too far, with the result that too much emphasis is placed on the psychosocial aspects of diagnosis and management, leading perhaps to this approach becoming a substitute for, rather than an added dimension to, conventional clinical methods? Would the doctor be better employed concentrating his skills on the technical aspects of medicine while at the same time working in close co-operation with the social worker, who would devote her energies to the patient's personal and emotional needs? This is an important book published at an opportune time. Some of its sections will be criticized fiercely, but I hope constructively. It is a pioneer work of immense industry which attempts to fulfil a need that has been evident for many years. It deserves to be read not only by teachers in general practice, but also by teachers in other fields of medicine.

This stimulating and provocative book has been written by a working party set up by the Royal College of General Practitioners and consisting of six outstanding general practitioners, all of whom have had extensive experience of teaching. The object of the book is to give guidance to teachers involved in the training of young doctors for a career in general practice. The larger part of the book is devoted to the content of vocational training and describes in detail what the authors consider to be the essential ground to be covered in postgraduate training in the setting of general practice. This section deals with health and disease, human development, human behaviour, medicine and society, and the organization of general practice, and provides a valuable practical guide which may provoke mild criticism but is unlikely to lead to heated discussion.
The same cannot be said for the chapters dealing with consultation in general practice. There will be many raised eyebrows as readers, if they are traditionalists and unfamiliar with the terms used, meet for the first time the language and approach of the behavioural scientists and the swing from the disease-centred approach on which most undergraduate teaching is based to the patient-centred approach advocated by the authors.
However, it would be a very unimaginative doctor, particularly if he has had experience in general practice, who is not stimulated by this approach to patient care, because all general practitioners are, or should be, familiar with the feeling of inadequacy induced by meeting a clinical situation which is not soluble in traditional medical terms. Expressed another way, the undergraduate is taught to make a diagnosis by collecting evidence which will lead him to deduce what morbid processes are at work and thence to determine what effect medical intervention will have on these processes. The authors put forward the view that this approach lacks the breadth and depth required in the management of patients in general practice and that unless we as doctors have a better understanding of the influence of the psychosocial component in illness we will be unable to meet the needs of our patients.
No doubt the authors would regard this as an oversimplified version of a most complex subject, but there is clearly a need to try to clear the air. Here we have a group of influential general practitioners who, at the instigation of an increasingly influential Royal College of General Practitioners, have written a book containing views which are perhaps not revolutionary, but are certainly unusual and will lead, I suggest, to the following questions being asked. Is this method of approaching patient care necessary, practicable, effective, and acceptable to the majority of patients in the setting of general practice as we know it today? If so how, and perhaps more important when, are we going to train doctors along the lines suggested? Is it really possible to influence doctors undergoing vocational training after five years of traditional undergraduate education and several years of traditional postgraduate training? Is there a danger that the pendulum may swing too far, with the result that too much emphasis is placed on the psychosocial aspects of diagnosis and management, leading perhaps to this approach becoming a substitute for, rather than an added dimension to, conventional clinical methods? Would the doctor be better employed concentrating his skills on the technical aspects of medicine while at the same time working in close co-operation with the social worker, who would devote her energies to the patient's personal and emotional needs? This is an important book published at an opportune time. Some of its sections will be criticized fiercely, but I hope constructively. It is a pioneer work of immense industry which attempts to fulfil a need that has been evident for many years. It deserves to be read not only by teachers in general practice, but also by teachers in other fields of medicine. This monograph is based on 116 cases (of which 82 are discussed in detail) of acute sudden hemiplegia in childhood which persisted for more than one week. All but seven were observed by the author. Being a personal experience, it benefits from a uniformity of approach, but suffers some lack of comprehensiveness and certainly has little statistical value.
The cases are classified into 24 categories on the basis of the clinical and angiographic findings. This results in some unnecessary subclassification. For example, to separate off "Moyamoya" disease from other forms of spontaneous cerebral arterial occlusion, and to theorize on differing aetiological factors in what seem to be really similar diseases producing different angiographic findingspossibly as a result of differing forms of collateral circulation-would appear to make a difficult subject even more complex. Nevertheless, the section on arterial occlusions is the most useful in this work, if only because it reflects some of the more recent contributions of angiography to the diagnosis of cerebral disease in children.
The rest of the work describes adequately the findings both clinical and investigatory in most of the recognized causes of acute hemiplegia in children. In some instances, the case numbers would appear rather small -for example, one case of cerebral abscess and two cases of saccular aneurysm, the latter dating back 20 years or more.
The illustrations of the radiological investigations are good, even though produced as positives. Line-drawings accompany most radiographs and are even duplicated in some cases in the first chapter. These should not be necessary where the radiographs are adquate, as most are. Where the radiographs are not adequate, they should not be reproduced, and a line-drawing substituted. Scanning procedures are not discussed and no mention is made of colour techniques in vascular malformations. No use seems to have been made of subtraction techniques which are very helpful in occlusive arterial disease, particularly where the vessels are obscured by bony structures.
The detailed case reports at the end of the work are a helpful appendix, and the references to the literature comprehensive and up-to-date. The value of the table of case histories is rather mnore doubtful. The style of the translated text is lucid. However, terminological confusion does creep in; whether in the original text or in translation one cannot say. For example, on page 8 in the space of one paragraph the terms "'arteriovenous aneurysm," "arteriovenous angioma," and "vascular malformation" are used to describe what appears to be the same condition.
The work illustrates many interesting cases, provides a good review of the literature, and shows the value of well-performed arteriography. However, there seems little in it that could not equally well be found in standard text books and in the current literature.